Form XXIII

[See rule 28 (1)]

Notice to the employer for an offence committed under the provisions of the Code for the first time for

compounding of offences under sub-section (1) of section 138

Notice No……………

Date:

On the basis of records and documents produced before me, the undersigned has reasons to believe that

you, being the employer of the establishment…………….. (Registration No………….), have committed an

offence for the violation of provision of the Code or the Schemes or the Rules or the Regulations framed

thereunder as per the details given below:-

PART – I

1. Name of the person:

2. Name and Address of the establishment:

3. Registration No. of the establishment:

4. Particulars of the offence:

Provisions of the Code/Scheme/Rules/Regulations under which the

5.

offence is committed:

Compounding amount required to be paid towards composition of

6.

the offence:

Name and details of account for depositing the amount specified in

7.

serial no. 6:

PART – II

In view of the above, you have an option to pay the entire amount mentioned in serial no. 6 in Part-I within

fifteen days from the date of issue of this notice and return the application duly filled in Part – III of this

notice.

In case the said amount is not paid within the specified time, necessary action for filing of prosecution shall

be initiated without giving any further opportunity in this regard.

(Signature)

(Name and designation of Officer)

Date:

Place:

To:

………………..(Employer/Establishment)

…………………(Name and registration number)

………………….(Address)

PART – III

[See rule 28 (2)]

Application under sub-section (4) of section 138 for compounding of offence

Ref: Notice No…………..

Date:

The undersigned has deposited the entire amount as specified in serial 6 of Part-I and the details of payment

are given below with a request to compound the offences mentioned in Part-I.

8. Details of the compounding amount deposited (Copy of electronically generated receipt to be attached):

9. Details of the prosecution, if filed for the violation of above-mentioned offences may be given:

10. Whether the offence is first offence or the applicant had committed any other offence prior to this

offence, if committed, then, full details of the offence:

11. Any other information which the applicant desires to provide:

Signature of the applicant

(Name and Designation)

Date:

Place:

To:

………………..(Compounding Officer)

…………………(Name of the Office)

………………….(Address)

PART – IV

[See rule 28 (3)]

Composition Certificate

Ref: Notice No…………..

Date:

This is to certify that the offence under sub-section ….. of section 133 in respect of which Notice No.

Dated: _____ was issued to Sh…………. (Applicant), the employer of ……………. (name and registration

number of establishment) has been compounded on account of remission of full amount of Rs ………..

(Rupees _________________) towards the composition of offences to the satisfaction of the said notice.

(Signature)

Name and Designation of the Officer

Date:

Place:

To:

………………..(Employer/Establishment)

…………………(Name and registration number)

………………….(Address)